Eating Disorder Assessment - Full

Rationale of Appointment Initial assessment Members of medical team present Dr. Thomas Kelly, Dr. Emily Carter Patient and relatives/friends present Patient and mother present Date of referral and source of referral Referred by GP on 20 October 2024 Physical Measurements & Observations Weight 65 kg Height 1.65 m BMI 23.9 ideal weight range, provide weights for BMI 19 - 25 51.8 kg - 68.0 kg Change since previous weight, including rate of change in kg/week Lost 2 kg in the last month, approximately 0.5 kg/week Heart rate 78 bpm Blood pressure 110/70 mmHg, sitting Oxygen saturations 98% on room air Capillary glucose 5.0 mmol/L SUSS test results Not performed Blood test results with dates Full blood count, electrolytes, liver function tests - 20 October 2024 History of Presenting Complaints Current issues and reasons for visit Patient presents with concerns about body image, fear of weight gain, and restrictive eating patterns. Associated symptoms with details Patient reports feeling anxious about food, engaging in compensatory behaviours such as excessive exercise, and experiencing low mood. Past Medical & Psychiatric History Past psychiatric diagnoses, treatments, hospitalisations Diagnosed with anxiety disorder at age 16, treated with CBT. Chronic medical conditions Nil Weight History Dieting history Patient has a history of dieting since age 14, including various restrictive diets. Weight cycling history Yes, patient reports fluctuations in weight over the past few years. Premorbid/usual weight 68 kg Body Image Body checking behaviours Patient frequently checks her body in the mirror and weighs herself multiple times a day. Body avoiding activities Patient avoids social situations involving food. Body image distortion Patient feels overweight despite being at a healthy weight. Disordered Eating / Eating Disorder Behaviours Restricting intake Patient restricts intake, particularly of carbohydrates and fats. Binge eating Patient reports occasional binge eating episodes. Overeating Patient reports feeling out of control around food. Self-induced vomiting No Exercise patterns/compulsivity Patient engages in excessive exercise, often for several hours a day. Rumination No Chewing and spitting No Laxative or diuretic use No Diet pill use No Misuse of prescribed medication No Other purging behaviours No Night eating No Eating Behaviour Hunger and fullness cues Patient struggles to recognise hunger and fullness cues. Food rules or fear foods Patient has a list of fear foods, including bread, pasta, and sweets. Allergies or intolerances Nil Vegan/vegetarian diet No Nutrition Intake Wake-up time and eating habits Patient wakes up at 7 am and typically skips breakfast. Breakfast Not eaten Morning snack Small apple Lunch Salad with grilled chicken Afternoon snack None Dinner Small portion of vegetables and lean protein Evening snack None Meals per day 2-3 Fluid intake 2 litres of water per day Physical Activity Behaviour Current activity Patient engages in cardio and weight training daily. Relationship with physical activity Patient feels anxious if she misses a workout. Menstrual History Age of onset 12 years Date of last period 15 October 2024 Usual cycle length 28 days Cycle regularity Regular Menstrual symptoms Mild cramping Contraception use Combined oral contraceptive pill Gut / Bowel Health Gut and bowel habits Regular bowel movements Medications Current medications, names, doses Sertraline 50mg daily, combined oral contraceptive pill Family History Family psychiatric or medical history Mother has a history of anxiety. Personal and Developmental History Pregnancy and Birth Complications during pregnancy or birth Nil Birth weight 3.2 kg Infancy and Early Childhood Developmental milestones: language, motor, coordination Normal Social and emotional development: attachment, comfort, play, emotional display Normal Early difficulties: developmental delays, tantrums, separation anxiety Nil School Years Educational performance: achievements, learning difficulties Good academic performance. Social relationships: friendships, bullying experiences Positive peer relationships. Emotional/behavioural issues: concentration, behaviour, mood Anxiety symptoms Adolescence and Adulthood Significant life events or stressors Transition to university. Social and occupational functioning Good social and occupational functioning. Substance use history: alcohol, drugs Occasional alcohol use. Social History Occupation and education level University student Current Substance use: smoking, alcohol, recreational drugs Occasional alcohol use. Social support Good social support from family and friends. Finacial situation Financially stable. Forensic history Nil Mental Status Examination Appearance Appears her stated age, well-groomed. Behaviour Anxious, restless. Speech Normal rate and rhythm. Mood Low mood. Affect Constricted. Thoughts Preoccupied with food and weight. Perceptions No perceptual disturbances. Cognition Intact. Insight Patient acknowledges the irrationality of her thoughts and behaviours. Judgment Good. Risk Assessment Suicidal ideation, intent, or self-harm risk No suicidal ideation or self-harm risk. Medical complications and treatment concordance Patient is medically stable. Protective factors and social support Strong social support from family and friends. Access to lethal means Nil Diagnosis Diagnosis and ICD-11 criteria, provide list of specific diagnostic criteria fulfilled Anorexia Nervosa, restricting type. Meets diagnostic criteria. Psychological scales/questionnaires Eating Disorder Examination Questionnaire (EDE-Q) score: 3.5 Treatment Plan Planned investigations Review blood test results. Medication plan: changes, continuations, discontinuations Continue Sertraline 50mg daily. Psychotherapy plans Recommend individual therapy with a specialist in eating disorders. Family meetings, collateral information, psychosocial interventions Involve family in treatment. Follow-up appointments and referrals Follow-up appointment in 2 weeks. Safety Plan Safety plan steps in crisis Contact therapist, call crisis line, reach out to family.